스위스 치즈 모델 기반 화학사고 분석에 관한 연구 -인도 Bhopal 사고 사례를 중심으로- = A Study on the Analysis of Chemical Accident Based on Swiss Cheese Model -Focusing on the case of India's Bhopal accident-

다국어 초록 (Multilingual Abstract)

The chemical accident that occurred in Bhopal, Madhya Pradesh, India in December 1984 immediately killed at least 2,000 people and caused respiratory or serious injury in 200,000 to 300,000.
Court proceedings are still underway some 40 years after the accident. This study was performed by reviewing research studies on the topic and systematically analyzing data using James Reason's Swiss cheese model and the General Error Modeling System (GEMS) to determine the cause of the accident.
Swiss cheese model analysis determined that the direct and indirect causes of the accident were lack of education, lack of personnel, incorrect operation, inappropriate facility design, and unsafe acts. Of these defects, unsafe acts included facility defects, management defects that caused them, and factors related to human error, and these acts were analyzed using James Reason's GEMS. In addition, psychological factors were found to contribute to these defects. Through this model analysis, types of occurrence factors of unstable behavior due to slip-lapse, rule-based error, knowledge-based error, and violation were derived to determine how psychological factors contributed to this accident.

참고문헌 (Reference)

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